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1、1,胃痛,Stomachache/Gastralgia,高健,2,Teaching objectives,了解胃痛的概念，范围 熟悉胃痛的病因病机 熟悉胃痛的诊断和鉴别诊断 掌握胃痛并发消化道出血的处理，各证型的症状特点与辨证施护了解预防与调养。,3,Definition,胃痛又称胃脘痛，是指上腹胃脘部近心窝处经常发生疼痛为主症，同时常兼见泛恶、脘闷、嗳气、大便不调等症。,4,Evolution History,“胃脘痛”之名最早记载于内经:素问六元正纪大论曰：“木郁之发，民病胃脘当心而痛。”唐宋以前文献多称胃脘痛为心痛，与属于心经本身病变的心痛相混。,伤寒论辨太阳病脉证并治说：“伤寒六七日，
2、结胸热实，脉沉而紧，心下痛，按之石硬，大陷胸汤主之。”,5,Evolution History,宋代之后医家对胃痛与心痛混谈提出质疑直至金元时代，兰室秘藏首立“胃脘痛”一门，将胃脘痛的证候、病因病机和治法明确区分于心痛，使胃痛成为独立的病证。明清时代进一步澄清了心痛与胃痛相互混淆之论，提出了胃痛的治疗大法，丰富了胃痛的内容,6,Scope,现代西医学中急性胃炎、慢性胃炎、胃溃疡、十二指肠溃疡、功能性消化不良、胃黏膜脱垂等病以上腹部疼痛为主要症状者，属于中医学胃痛范畴，均可参考本节进行辨证论治，必要时结合辨病处理。,7,病因病机Etiology&pathogenesis,8,Etiology&p
3、athogenesis,胃痛的发生，主要由外邪犯胃、饮食伤胃、情志不畅和脾胃素虚等，导致胃气郁滞，胃失和降，不通则痛。,9,Etiology&pathogenesis,外邪犯胃 外感寒、热、湿诸邪，内客于胃，皆可致胃脘气机阻滞，不通则痛。其中尤以寒邪为多，如素问举痛论说：“寒气客于肠胃之间，膜原之下，血不能散，小络急引，故痛。”,10,Etiology&pathogenesis,饮食伤胃不节，或过饥过饱，损伤脾胃，胃气壅滞，致胃失和降，不通则痛。五味过极，辛辣无度，肥甘厚腻，饮酒如浆，则蕴湿生热，伤脾碍胃，气机壅滞。,医学正传胃脘痛说：“致病之由，多由纵恣口腹，喜好辛酸，恣饮热酒复餐寒凉生冷，
4、朝伤暮损，日积月深故胃脘疼痛”。,11,Etiology&pathogenesis,情志不畅忧思恼怒，伤肝损脾，肝失疏泄，横逆犯胃，脾失健运，胃气阻滞，均致胃失和降，而发胃痛。气滞日久或久痛人络，可致胃络血瘀。,12,Etiology&pathogenesis,素体脾虚脾胃为仓廪之官，主受纳及运化水谷，若素体脾胃虚弱，运化失职，气机不畅，或中阳不足，中焦虚寒，失其温养而发生疼痛。,13,寒邪克胃，寒凝气滞，胃气失和 饮食不节，损伤脾胃，运化无权 情志不遂，肝失疏泄，横逆犯胃 劳倦久病，脾胃虚弱，升降失司 胃痛病位与胃、肝、脾关系最为密切。初起多属实证，病位主要在胃，间可及肝，病久常见虚证，病位
5、主要在脾，或脾胃同病，或肝脾同病。其基本病机是胃气失和，气机不利，胃失濡养，不通则痛。,病因病机小结Summery of etiology&pathogenesis,14,诊断 Diagnosis,鉴别诊断 Differential diagnosis,&,15,上腹近心窝处胃脘部发生疼痛为特征，其疼痛有胀痛、刺痛、隐痛、剧痛等不同的性质。常伴食欲不振，恶心呕吐，嘈杂泛酸，嗳气吞腐等上消化道症状。发病特点：以中青年居多，多有反复发作病史，发病前多有明显的诱因，如天气变化、恼怒、劳累、暴饮暴食、饥饿、进食生冷干硬辛辣醇酒，或服用有损脾胃的药物等。,诊断 Diagnosis,16,鉴别诊断 Dif
6、ferential diagnosis,胃痛与真心痛 真心痛是心经病变所引起的心痛证。多见于老年人，为当胸而痛，其多刺痛，动辄加重，痛引肩背，常伴心悸气短、汗出肢冷，病情危急，正如灵枢厥论曰：“真心痛手足青至节，心痛甚，旦发夕死，夕发旦死。”其病变部位、疼痛程度与特征、伴有症状及其预后等方面，与胃痛有明显区别。,17,鉴别诊断 Differential diagnosis,胃痛与胁痛 胁痛是以胁部疼痛为主症，可伴发热恶寒，或目黄肤黄，或胸闷太息，极少伴嘈杂泛酸、嗳气吐腐。肝气犯胃的胃痛有时亦可攻痛连胁，但仍以胃脘部疼痛为主症。两者具有明显的区别。,18,寒邪客胃:retention patho
7、genic cold in stomach 饮食停滞:肝气犯胃:liver-qi attacking stomach肝胃郁热瘀血停滞:retention of blood stasis胃阴亏虚:consumption of gastric yin脾胃虚寒:asthenia-cold in spleen and stomach,Analyses of pathological conditions,19,Retention pathogenic cold in stomach 胃痛暴作，恶寒喜暖，得温痛减，遇寒加重，口淡不渴，或喜热饮，苔薄白，脉弦紧。饮食停滞 胃痛，脘腹胀满，嗳腐吞酸，或吐不消
8、化食物，吐食或矢气后痛减，或大便不爽，苔厚腻，脉滑。Liver-qi attacking stomach 胃脘胀闷，攻撑作痛，脘痛连胁，嗳气频繁，大便不畅，每因情志因素而痛作，苔多薄白，脉沉弦。,Analyses of pathological conditions,20,肝胃郁热 胃脘灼热，痛势急迫，烦躁易怒，泛酸嘈杂，口干口苦，舌红苔黄，脉弦或数。Retention of blood stasis 胃脘疼痛，痛有定处而拒按，或痛有针刺感，食后痛甚，或见吐血黑便，舌质紫黯，脉涩。,Analyses of pathological conditions,21,Consumption of ga
9、stric yin 胃痛隐隐，口燥咽干，大便干结，舌红少津，脉细数。Asthenia-cold in spleen and stomach 胃脘隐隐作痛，喜温喜按，空腹痛甚，得食痛减，泛吐清水，纳差，神疲乏力，甚则手足不温，大便溏薄，舌淡苔薄，脉虚弱或迟缓。,Analyses of pathological conditions,22,Stomachache/Gastralgia,Problems of patients:Nursing goals:,23,Stomachache/Gastralgia,Nursing interventionsRetention pathogenic cold
10、 in stomachPrinciple of nursing：温胃散寒，理气止痛Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:：Tui na：Other nursing methods：,香苏散合良附丸加减。常用药：高良姜、吴茱萸温胃散寒；香附、乌药、陈皮、木香行气止痛。,24,Stomachache/Gastralgia,Nursing interventions饮食停滞Principle of nursing：消食导滞Entirety nursing,Life care：Diet care：Drugs care：A
11、cupuncture:：Tui na：Other nursing methods：,保和丸加减。常用药：神曲、山楂、莱菔子消食导滞；茯苓、半夏、陈皮和胃化湿；翘散结清热。,25,Stomachache/Gastralgia,Nursing interventionsLiver-qi attacking stomachPrinciple of nursing：疏肝理气，和胃止痛Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:：Tui na：Other nursing methods：,柴胡疏肝散加减。常用药：柴胡、芍药、川芎
12、、郁金、香附疏肝解郁；陈皮、枳壳、佛手、甘草理气和中。,26,Stomachache/Gastralgia,Nursing interventions肝胃郁热Principle of nursing：疏肝清热和胃Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,27,Stomachache/Gastralgia,Nursing interventionsRetention of blood stasisPrinciple of nursing：活血化瘀止痛Entir
13、ety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,失笑散合丹参饮加减。常用药：蒲黄、五灵脂、丹参活血散瘀止痛；檀香、砂仁行气和胃。,28,Stomachache/Gastralgia,Nursing interventionsConsumption of gastric yinPrinciple of nursing：养阴益胃Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nur
14、sing methods：,一贯煎合芍药甘草汤加减。常用药：沙参、麦冬、生地、枸杞子养阴益胃；当归养血活血；川楝子理气止痛；芍药、甘草缓急止痛。,29,Stomachache/Gastralgia,Nursing interventionsAsthenia-cold in spleen and stomachPrinciple of nursing：温中健脾Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,黄芪建中汤加减。常用药：黄芪补中益气；桂枝、生姜温脾散寒；芍
15、药、炙甘草、饴糖、大枣缓急止痛。,30,Stomachache/Gastralgia,Nursing evaluationIntroduction on health讲究饮食卫生，饮食有节，定时定量，勿暴饮暴食，戒烟酒。注意胃脘部保暖。或用手掌自上脘向下按摩胃脘部，反复作20次，每日数次，可增强脾胃功能。查明引起胃痛的原因，积极治疗原发病，若反复发作，迁延不愈，应定期做有关检查，防止恶变。,31,泄泻（Diarrhea）,主讲：高健,32,Diarrhea,Definition Diarrhea 是指排便次数增多，粪质稀薄或完谷不化，甚至泻出如水样为特征的病证。以大便溏薄，病势缓者为泄；大便清
16、稀如水，直下者为泻。本病可发生在一年四季，以夏秋季节多见。,33,Diarrhea,Cause of Disease and Pathomechanism感受外邪饮食所伤情志失调久病体虚 泄泻的病变主要在脾胃，并涉及大、小肠、肝、肾。其病机为脾虚湿盛。因湿盛而致脾病者，多为暴泻；因脾虚失运，湿邪壅滞者，多为久泻。,34,Diarrhea,Analyses of pathological conditions寒湿（风寒）:cold-damp(wind-cold)湿热（暑湿）:damp-heat(summer damp)食滞胃脘:retention of food in stomach肝气乘脾:l
17、iver-qi attacking spleen脾胃虚弱:weakness/hypofunction of spleen and stomach肾阳虚衰:declination of renal yang,35,Diarrhea,Analyses of pathological conditionsCold-damp(wind-cold)泻下清稀，甚则如水样，腹痛肠鸣，脘闷食少，或兼恶寒发热，头痛，肢体酸痛，苔薄白或白腻，脉濡缓。Damp heat(summer damp)腹痛即泻，泻下急迫，或泻而不爽，粪色黄褐而臭，肛门灼热，烦热口渴，小便短赤，舌苔黄腻，脉濡数或滑数。,36,Diarrhe
18、a,Analyses of pathological conditionsRetention of food in stomach 腹痛肠鸣，泻下粪便臭如败卵，泻后痛减，大便伴有不消化之物，脘腹痞满，嗳腐酸臭，不思饮食，舌苔厚腻或垢浊，脉滑。Liver-qi attacking spleen 每因抑郁恼怒或情绪紧张之时，即发生腹痛泄泻，便后腹痛略减；平时多有胸胁；胀闷，嗳气食少，舌淡红，脉弦。,37,Diarrhea,Analyses of pathological conditionsWeakness/hypofunction of spleen and stomach 大便不实，时溏时泻，
19、每因稍进油腻之物，则便次增多，甚则挟有不消化之物，饮食减少，脘腹胀闷不舒，面色萎黄，肢倦乏力，舌淡，苔白，脉细弱。Declination of renal yang 泄泻多在黎明之前，脐腹隐痛，肠鸣即泻，泻后则安，腰膝痰软，形寒肢冷，舌淡苔白，脉沉细。,38,Diarrhea,Problems of patients,39,Diarrhea,Nursing interventionsCold-damp(wind-cold)Principle of nursing：解表散寒，芳香化浊Entirety nursing,Life care：Diet care：Drugs care：Acupunctu
20、re:Tui na：Other nursing methods：,40,Diarrhea,Nursing interventionsDamp heat(summer damp)Principle of nursing：清热利湿Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,41,Diarrhea,Nursing interventionsRetention of food in stomachPrinciple of nursing：消食导滞Entirety nu
21、rsing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,42,Diarrhea,Nursing interventionsLiver-qi attacking spleenPrinciple of nursing：抑肝扶脾Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,43,Diarrhea,Nursing interventionsWeakness/hypofu
22、nction of spleen and stomachPrinciple of nursing：健脾益胃Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,44,Diarrhea,Nursing interventionsDeclination of renal yangPrinciple of nursing：温肾健脾，固涩止泄Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:：Tui na：O
23、ther nursing methods：,45,Diarrhea,Nursing evaluationIntroduction on health加强饮食卫生和水源管理，讲究个人卫生，饭前便后要洗手，防止“病从口入”。饮食宜新鲜，不可过食生冷之品，禁食一切不洁及腐败食物。生活起居有节，防止外感风寒暑湿之邪。,46,黄疸（Jaundice/Icterus）,主讲：高健,47,Jaundice/Icterus,Definition 黄疸是以身黄、目黄、小便黄为主症的疾患，其中目晴黄染为本病的重要特征。根据其病机特点和临床表现，黄疸有阴黄、阳黄之分，急黄乃阳黄之重症，应及时救治。,48,Jaund
24、ice/Icterus,Cause of Disease and Pathomechanism感受外邪 饮食不节脾胃虚寒积聚转化砂石、虫体阻滞胆道 黄疸形成的关键是湿邪为患。病位在脾胃肝胆，脾胃运化失健，肝胆疏泄失常，胆汁不循常道，外溢肌肤，下流膀胱而见身目小便俱黄。,49,Jaundice/Icterus,Analyses of pathological conditionsYang jaundice：身目俱黄，黄色鲜明，脘腹胀满，食欲减退，恶心呕吐，小便短赤，大便秘结，舌红苔黄厚，脉濡缓或弦数。若热较重可见发热、口渴、心烦；湿较重可见身热不扬、渴不欲饮。Acute jaundice：黄疸急
25、起，迅速加深，其色如金，高热烦渴，神昏谵语，尿少便秘，或躁动抽搐，衄血便血，肌肤瘀斑，舌红绛，苔黄而燥，脉弦滑或细数。Yin jaundice：身目俱黄，其色晦暗或浅淡，脘腹胀闷，纳少便溏，神疲畏寒，或心悸气短，舌淡苔白腻，脉沉迟或濡细。,50,Jaundice/Icterus,Problems of patientsNursing goals,51,Jaundice/Icterus,Nursing interventionsYang jaundicePrinciple of nursing：清热利湿退黄Entirety nursing,Life care：Diet care：Drugs ca
26、re：Acupuncture:Tui na：Other nursing methods：,52,Jaundice/Icterus,Nursing interventionsAcute jaundicePrinciple of nursing：清热解毒，凉血散瘀Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:Tui na：Other nursing methods：,53,Jaundice/Icterus,Nursing interventionsYin jaundicePrinciple of nursing：健脾和胃，温寒化湿Entirety nursing,Life care：Diet care：Drugs care：Acupuncture:：Tui na：Other nursing methods：,54,Jaundice/Icterus,Nursing evaluationIntroduction on health黄疸具有传染性，应加强防疫措施，做到早发现，早诊断，早隔离，早治疗，早处理。加强对环境、牲畜、水源的管理，注意饮食卫生，饮食餐具应煮沸消毒。积极治疗原发病，如胆石症、肿瘤、肝炎可注射肝炎疫苗，或在流行期间预防用药。,
